Magazine article American Nurse Today

On the Road to Zero CAUTIs: Reducing Urinary-Catheter Device Days: How a Culture Shift, a Quality-Improvement Project, and Electronic Solutions Reduced One Hospital's CAUTI Incidence

Magazine article American Nurse Today

On the Road to Zero CAUTIs: Reducing Urinary-Catheter Device Days: How a Culture Shift, a Quality-Improvement Project, and Electronic Solutions Reduced One Hospital's CAUTI Incidence

Article excerpt

Catheter-associated urinary tract infections (CAUTIs) are common healthcare-associated infections that can prolong lengths of stay and increase morbidity and mortality. Despite their best efforts, many hospitals continue to struggle with climbing CAUTI rates. Recognizing inappropriate or prolonged urinary catheterization as a primary risk factor, our team decided to target urinary-catheter device days as a way to reduce CAUTIs.

The specific aim of this quality-improvement initiative was to decrease the number of urinary catheters inserted and reduce the time they stayed in place. Each additional day of indwelling catheterization further increases the risk of developing a CAUTI. We anticipated that by inserting fewer catheters and removing them earlier, we would decrease CAUTI incidence.

Targeted areas for improvement included all five of the noncritical care units at our 140-bed community medical center. At the start of this initiative, our critical care unit was exceeding at preventing device-associated infections, but our medical-surgical units were seeing a higher-than-expected CAUTI incidence. As we approached 2013, a system-wide task force was poised to introduce several evidence-based initiatives aimed at reducing CAUTIs.

In addition to the task-force solutions intended to standardize the evidence-based processes used with urinary catheters, our team added several other strategies to enhance our culture of safety and accountability around urinary catheters. To monitor our progress, we identified the urinary catheter device-utilization ratio (DUR) and actual number of CAUTIs as performance measures. Reported monthly, the DUR reflects the proportion of total patients with indwelling urinary catheters. Before our project began, validation studies were done to ensure the accuracy of DUR reporting. CAUTIs were identified and reported by the infection preventionist.

Electronic solutions

In January 2013, we implemented several electronic solutions to support our goal of reducing urinary catheter device days. We also implemented evidence-based indications for urinary catheter insertion and maintenance, based on guidelines from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Association for Professionals in Infection Control and Epidemiology (APIC), recommended by the system-wide task force for CAUTI prevention. (See Evidence-based indications for indwelling urinary catheters).

Time-limited catheterization orders and a nurse-driven protocol for catheter removal were the primary electronic solutions supporting this initiative. We also implemented:

* an algorithm for bladder scanning and intermittent catheterization for failure to void

* electronic alerts to remind physicians and nurses when a temporary catheter had been in place more than 48 hours

* revised nursing flowsheets to align our documentation with intervention-bundle recommendations from HICPAC and APIC. These interventions reinforced our commitment to keeping each catheter in place only as long as medically indicated.

Clinician education and training

Recognizing the importance of clinician education and training to improve outcomes and prevent complications related to urinary catheters, we partnered with the manufacturer of our urinary catheters to develop and implement a training program aimed at expanding knowledge and improving catheter insertion and maintenance competencies. Each unit identified a nurse champion to attend this special training event. In addition to acquiring knowledge and skills, champions learned strategies for sharing the information at the unit level.

As part of the training program, skill stations were set up to review competencies and update techniques. Training emphasized the maintenance bundle and daily reevaluation of the continued need for a catheter.

Nurses aren't the only clinicians who interact with catheterized patients, so a special session was held for non-nursing staff, such as physical therapists and transport personnel. …

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